Hemorrhoidal disease is a widespread disease in industrialized nations that is rarely talked about. It is estimated that as many as 50% of adults experience symptomatic hemorrhoids once in their lives.
Everything tight? Everyone needs hemorrhoids
Hemorrhoids are extensions of the corpora cavernosa in the anal canal, which play an important role in stool and wind control and also occur in healthy people. Only when the vessels of the erectile tissue are abnormally dilated and become symptomatic can one speak of a hemorrhoidal disease. This usually causes nonspecific symptoms that can be very distressing. These include:
- bloody deposits on chair and toilet paper
- Itching and burning in the anal region
- Pain during bowel movements
The usual suspects: diet, exercise, weight
Many different factors are involved in the development of hemorrhoidal disease, which is why it is also called a multifactorial genesis of the disease. In addition to a wrong diet may also be lack of exercise, overweight and a family disposition jointly responsible for the Hämorrhoidalleiden.
Pregnancy continues to be a special situation: up to 50% of all women suffer from discomfort in the anal region. Because the body changes in this time in such a way that the development of a Hemorrhoidalleidens is promoted.
Depending on the severity of the symptoms and size of the hemorrhoids, a classification into four stages is carried out. While the first two stages can only cause mild symptoms and can often be treated with conservative measures such as stool control and weight reduction, stage III and IV sometimes present serious symptoms that can only be controlled by long-term surgery.
Although discomfort in the anal region is widespread, the doctor is relatively rarely visited, which is fatal, since the suffering does not exist by itself untherapiert. On the contrary, the symptoms often worsen considerably over time.
An important function of the rectum or anal canal is chair and wind control. This is ensured by various structures, which in their entirety form the so-called continence organ. The most important components of the continence organ are the sphincter system and the erectile tissue.
The sphincter system consists of three muscle rings, which surround the bowel outlet circularly and can consciously or unconsciously constrict controlled, so as to restrain solid and liquid intestinal contents. This is important, for example, when the pressure in the abdomen increases when laughing or lifting heavy objects and intestinal content is pushed towards the intestinal outlet.
Our 10 most important tips against hemorrhoids
The erectile tissue in turn consists of a circular vascular pad, which is fed by arteries. The drainage takes place partly through the sphincter muscles into the venous blood system. If there is a contraction of the sphincter muscles, the blood can not drain from the erectile tissue, resulting in a swelling of the vascular network. This mechanism is especially important for a gastight seal of the intestinal exit.
The term hemorrhoids is understood to mean extensions of the corpus cavernosum in the anal canal (corpus cavernosum recti), which make an important contribution to continence maintenance. Hemorrhoids alone, unlike common usage, are not yet a disease, but a natural and important device of the body. Hemorrhoids are considered pathological only when they enlarge too much, bulge into the anal canal and lead to symptoms. In this case, it is then correctly spoken of a Hämorrhoidalleiden.
Hemorrhoidal disease is not uncommon in Germany or Western industrial nations. Estimates suggest that every second person has morbidly enlarged hemorrhoids. However, as the disease is often mild, many cases go undetected, so the exact numbers are unknown.
Important basic questions about hemorrhoids
The exact causes that can lead to Haemorrhoidalleiden are not yet sufficiently secured.However, there are a number of risk factors associated with the onset of symptomatic hemorrhoids. These include:
- familial predisposition to connective tissue weakness
- faulty diet that contains too little fiber
- insufficient fluid intake
- predominantly sedentary activities or long sitting
- An increased pressure in the abdomen, for example, by carrying heavy lasses, coughing or strong pressing at the toilet
Increased pressure in the abdomen
A special position in the development of Hämorrhoidalleidens assumes a false Defäkationsverhalten. For example, chronic obstruction often leads to excessive pressure, which increases the pressure in the abdomen and can lead to an outflow of the vascular pad in the anal area. An increased intra-abdominal pressure exists especially when lifting heavy loads, coughing or sneezing, but also overweight and during pregnancy.
Likewise, pulpy bowel movements against an insufficiently relaxed sphincter system can lead to haemorrhoidal disease.
Diet: without fiber it does not work around
Nutrition also plays a major role in the development of hemorrhoidal disease. In particular, the lack of indigestible, but water-binding fiber and fruit fibers (for example, stone fruit) can lead to a too hard bowel movement. Because the less fiber is added to the body, the less water is contained in the stool and the smaller its mass. This in turn means that the intestine is not sufficiently stimulated to move the chair towards the anus. As a result, constipation occurs. A similar mechanism occurs with insufficient fluid intake. Again, the body reduces stool mass by removing more water from food. The stool thickens and the intestines become sluggish.
Pregnancy: heavy weight and flabby tissue
Especially in pregnancy, symptomatic hemorrhoids are common. This has several reasons:
On the one hand, weight gain increases intraabdominal pressure and increases blood volume. And on the other hand, the pregnancy hormones estrogen and Progesterone ensure that the tissue is more elastic and also easier to bulge vessel walls. A newly arising Hämorrhoidaliden in pregnancy is therefore not uncommon, but rather the rule.
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Questions and answers about the causes
The extent of the complaints of hemorrhoidal disease depends not only on the size of the hemorrhoid, but rather on the severity of the disease.
Red toilet paper, itching and burning
While early stage hemorrhoids often do not cause any symptoms, there are usually many different, uncharacteristic symptoms that can also occur in other rectal diseases. Typical complaints are:
- painless, bright red bleeding that occurs during or after defecation; typical are bright red traces of blood on the toilet paper or on the remote chair.
- Inflamed skin in the area of the anus, which may be accompanied by itching, burning or mucous secretion
- involuntary departure of chair or wind
- Foreign body sensation and feeling of incomplete evacuation
- On the other hand, pain rarely occurs (usually only at an advanced stage).
The symptoms listed are very unspecific and occur in addition to the Hämorrhoidalleiden in a number of other diseases of the rectum. Precisely for this reason, you should always have persistent, severe or restrictive complaints clarified by a doctor. Especially with blood, which is found in the stool or on the toilet paper, the exclusion of colon cancer always has to be done.
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Symptoms and complaints
Hemorrhoids may be divided into four stages or degrees of severity depending on the severity or extent of the episode in the Goliger anal canal (prolapse). This classification is especially important for therapy planning and prognosis of the disease and is routinely used in the diagnostic evaluation of Hemorrhoidalleidens.
|Grade I||In Goligher stage I, the hemorrhoids are only slightly enlarged, do not cause discomfort and are visible only as a reflection of the rectum or anal canal (proctoscopy). An important feature of this stage is that the hemorrhoids are reversible, so they can completely and naturally regress.|
|Grade II||In stage II, it is characteristic for the pressing, coughing or lifting of heavy loads that the hemorrhoids emerge from the anal canal. The erectile tissue is visible from the outside, especially during bowel movements, but then withdraws back into the anal canal by itself (self-repositioning).|
|Grade III||Goligher stage III is characterized by a spontaneous emergence of enlarged hemorrhoids from the anal canal (prolapse) independent of defecation. Unlike Stage II, there is no self-reordering. The prolapsed swelling body parts are only manually, so with the hands, pushed back into the anal canal.|
|Grade IV||In the fourth and last stage, a fixed prolapse finally occurs, which permanently comes to rest in front of the anal opening and can not be relocated manually. The hemorrhoids are thus always visible and may also be associated with pain at this stage.|
Since the symptoms of hemorrhoidal disease are very nonspecific, you should always consult a doctor for painful defecation, pressure sensation in the anal area or when blood deposits on the chair or the toilet paper occur. This will first clarify in a detailed medical history risk factors that are associated with a Hämorrhoidalleiden.
Bright blood speaks for hemorrhoids
Furthermore, he will inquire about the noted blood deposits on the toilet paper or on the chair. While hemorrhoids typically lead to bright red bleeding, darker bowel movements or dark to black blood may be an indication of a higher localized source of bleeding that is not typical of hemorrhoids.
Following the anamnesis interview, a complete physical examination will be carried out, including palpation of the rectum or anal canal (digital rectal examination). An experienced doctor can feel his knot-changing hemorrhoids with his finger.
Must be: reflection of anal canal and intestine
To confirm the diagnosis, a reflection of the anal canal must be carried out during the course of the procedure (proctoscopy). A rigid metal tube (proctoscope) is inserted from rectally approx. 10-15 cm deep into the anus. When slowly withdrawing the device, the anal canal can be examined for the presence of hemorrhoids. The examination usually lasts only a few minutes and, unlike the colonoscopy (colonoscopy), without previous complete defecation.
Since blood in the stool and changes in bowel habits always have to be thought of colon cancer, in addition to the diagnosis of Hämorrhoidalleidens a colonoscopy should be performed (colonoscopy). As part of the colonoscopy, the entire colon can be viewed and examined for an altered mucosa. From suspicious areas a trial biopsy can be taken, so that the exclusion of a colon or rectal tumor as a differential diagnosis of Haemorrhoidalleidens can be safely excluded.
Everything important for diagnostics
The treatment of Hämorrhoidalleidens is usually required only for complaints and takes place depending on the stage. While the first two stages are conservative or interventional, multiple operations are required in stages III and IV to alleviate the symptoms.
Especially if you are plagued by advanced hemorrhoidal disease, you should consult a general practitioner (proctologist) prior to treatment to discuss the possible treatment options.
1. Conservative therapeutic approaches
The conservative therapeutic approach aims to reduce the risk factors of hemorrhoidal disease and alleviate the symptoms symptomatically.
It works better with a soft chair
An important component of this therapy pillar is the regulation of stools, as many of the complaints caused by the hemorrhoids can be the result of constipation. A chair that is too hard leads to excessive pressure build-up (pressing) when using the toilet, which in turn favors the development of abnormally enlarged hemorrhoids. So be sure to get a soft stool so you can empty your bowels without much effort.
The most important chair-regulating measures include:
- A high-fiber diet of lots of fresh fruits, vegetables, whole grains and dried fruit: fiber provides more stool volume by binding water in the gut. This in turn leads to an increased intestinal peristalsis and consequently to an easier defecation.
- enough physical exercise: Try to incorporate exercise into your everyday life, for example by cycling to work or not taking the lift home, but taking the stairs to the fourth floor. Even small behavioral changes can achieve great success!
- the renunciation of flatulent, sugared or too fatty foods
- adequate hydration of at least one and a half liters of water or unsweetened tea a day
Furthermore, a so-called toilet stool can be used. This is nothing more than a kind of footstool, on which the feet are placed during the toilet. The resulting position is anatomically best suited to deflate the intestine relaxed and to avoid pressure build-up.
Pay attention to hygiene and care
Another important conservative therapy approach to alleviate hemorrhoidal disease is a thorough anal hygiene that aims to soothe the anal mucosa:
- Thoroughly cleanse your bowel outlet after every flush. But be careful not to hurt the anal mucosa by excessive friction or too hard toilet paper.If necessary, slightly dampen the toilet paper with warm water and dab the anal area.
- Avoid industrially manufactured cosmetics, soaps or moist wipes for anal care. Fragrances and other additives can cause irritation and maintain existing inflammation.
- Try a lukewarm sitzbad with natural bath additives such as chamomile flowers or oak bark. Although the benefits of this application are controversial in the literature in terms of its healing properties, it is often found to be very soothing and soothing.
Ointments can have a soothing effect
In the pharmacy, there are a number of products that should lead to a reduction in the complaint of hemorrhoidal disease. For mild symptoms, zinc, fat, or aloe-based ointments may be used. These are intended to provide reliable relief in stages I and II and can be purchased without a doctor's prescription.
However, when using these ointments, always remember that this will not remedy the cause of your condition, but only relieve symptoms such as itching or pain while the underlying condition persists.
The ointments are introduced into the anal canal after each bowel movement and thorough anal hygiene. Most tubes are specially shaped for this purpose, so the application is usually simple. After use, thorough cleaning should be done, especially at the tip of the tube, to avoid bacterial colonization.
Over-the-counter ointments that can be used in a known hemorrhoidal disease are:
- faktu® Hemorrhoids ointment: The herbal ingredient Hamamelis is contained in this preparation as a concentrated distillate. The ointment is especially useful at an early stage of hemorrhoidal disease as it has anti-inflammatory properties and promotes anal wound healing. The ointment has no influence on the size of the hemorrhoids.
- HemoClin® Gel: HemoClin is not an ointment but a gel whose herbal active ingredient comes from the Aleo Barbadensis plant. The gel has a cooling effect and inhibits bacterial growth so that it does not come to a bacterial relocation of the anus. Especially the cooling effect is perceived as pleasant, but does not last long.
- Haenal® Fact Hamamelis ointment: The Hamamelis plant is processed in this preparation, but the bark. In addition, Vaseline, wool wax alcohols and peppermint oil are important components of this ointment. The composition is particularly effective for mild bleeding, itching and a burning sensation, which may occur especially in the early stages of hemorrhoidal disease.
- Hametum® Wound and healing ointment: The Hametum wound and healing ointment, the ingredient of which is Hamamelis, is not only well suited for hemorrhoids. The ointment has the advantage that it lays on the affected area like a protective sheath for minor skin and mucosal injuries and thus promotes regeneration. Also, it can be used only in mild forms of Hämorrhoidalleidens.
- Posterisan® acute. The ointment, designed for the acute case, relieves local pain and itching, thus ensuring a quick relief of the symptoms. The active ingredient is lidocaine, which has a local anesthetic effect and provides relaxation.
Furthermore, special anal tampons can be used to quicken minor bleeding and provide relief by compressing the hemorrhoid.
For pain or more severe symptoms, the doctor may prescribe lidocain or Cortisone ointments. Lidocaine is a topical anesthetic that stuns the skin at the point of use and so regulates pain. Cortisone has a decongestant effect, but should only be used for a short time as it leaves the skin thin and brittle when used too long.
2. Interventional therapy
Interventional therapy approaches are used in stages I and II.
Cut off the blood supply from the hemorrhoids
In stage I, the sclerotherapy technique is predominantly used. Here, the doctor injects a drug in the enlarged hemorrhoids, which leads to their desolation. The vessels are thereby first fixed and rigid by the reduced blood flow and then degraded by the body.
The advantage of this technique is that it is a small procedure that usually does not involve complications. Also pain or other complaints do not usually occur. A major disadvantage is that only minor vascular changes can be treated with it and several sessions are required.
In stage II, the rubber band ligation is mainly used for this reason. In this therapy method, the treating physician binds the changed or enlarged hemorrhoids with the help of a rubber band. This leads to an interruption of the blood supply, the tied knots die off and are then broken down by the body.
In the rubber band ligation it can cause pain in the anal area as well as a foreign body sensation, sometimes bleeding occurs. Nevertheless, this therapy method is a good alternative to sclerotherapy or surgery in stage II.
In severe cases, when sclerotherapy and rubber band ligation are no longer effective and the suffering is too great, a hemorrhoid surgery should be performed.Depending on the degree and severity of the hemorrhoids different surgical techniques are used.
While the morbidly dilated hemorrhoids were previously completely surgically removed (hemorrhoidectomy), today it is increasingly going on to carry out a forklift operation to Longo. In this technique, only a portion of the enlarged hemorrhoid is removed, while the remainder is fixed to the anal mucosa.
A decisive advantage of this method is that the corpus cavernosum is removed only to small parts and is thus not completely deprived of its function by the surgical procedure. Wind and chair continency keep safe.
4. Quick help with acute symptoms
Hemorrhoids become symptomatic especially when it is least needed. For example, during a cold (by coughing and nursing) or during gardening (by staying in a squat position for a long time).
Especially in the case of a newly occurred Hämorrhoidalleiden at the beginning of many attempts are made to get the complaints themselves under control and thus avoid the visit to the doctor. In any case, seek out a doctor if the symptoms become too strong or unpleasant or if you are unsure by the symptoms, whether it is actually an uncomplicated Hämorrhoidaleriden.
Can be very beneficial: a warm sitz bath
For symptomatic self-treatment, a sitting bath can be taken in light forms or a treatment trial with ointments and compresses can be undertaken. In addition, you should avoid sitting too long, taking care to avoid triggering factors (such as pressing while using the toilet).
For heavier forms, a manual reduction can be attempted by hand. This works best in the prone position with the help of lukewarm compresses, but should be carried out very carefully and independently best only after medical instruction.
A very important credo is in any case: be patient. A Hämorrhoidalleiden unfortunately does not disappear as quickly as it has come. Particularly annoying symptoms such as itching and small mucosal injuries in the anal area heal only slowly and return frequently.
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Important questions and answers about the treatment
Hemorrhoidal disease is an unpleasant condition. But it can be treated well, especially if it is detected and treated early.
Even if it costs you to overcome, do not be afraid to see a doctor. The sooner you start treatment, the greater the chances of long-term freedom from symptoms. Especially interventional and operative therapeutic approaches are promising and sustainable, while symptomatic attempts at self-treatment provide in many cases only temporary relief of the symptoms.
You have it in your own hands!
Unfortunately, enlarged hemorrhoids, even after successful treatment, can return again and again. In many cases, however, this is not due to late or incorrect treatment, but is often due to the fact that insufficient attention is paid to general measures such as proper chair regulation and anal hygiene.
So even after completing therapy for hemorrhoidal disease, ensure that you have a balanced diet, sufficient exercise, and an analgesic-free anal mucosa. Only then can the success of a therapy be permanently maintained.
Questions about the prognosis
Author: Lisa Wunsch
German Society for Coloproctology: S1 Guideline "Hemorrhoidal Disease", http://www.awmf.org/uploads/tx_szleitlinien/081-007e_S1_Haemorrhoidalleiden_2008_abgelaufen.pdf, last accessed on 2017-07-22.
M. Müller: "Surgery: for study and practice", medical publishing and information services.
J. Hahn: Checklist Internal Medicine, Thieme Verlag.
Comment: the most important questions and answers about hemorrhoids
Everyone has hemorrhoids. Hemorrhoids are not a disease, but normal vascular structures in the rectum area, which exercise a fine-regulating function in the "big business". In everyday language, however, the term is equated with hemorrhoidal disease, as it would be called medically correct. This is similar to "I have backs ...". But even for the disease version, the first sentence seems almost accurate. Large parts of the German population suffer more or less from their hemorrhoids. Women and men are affected about equally frequently. The 3.5 million cases of treatment in Germany are counted each year.
Widely used taboo theme
And although so many people are affected by it, little is talked about. Especially out of shame. For the same reason, the doctor's visit is often avoided or postponed until the symptoms exceed the tolerable level. Not infrequently, even a multi-day hospital stay is required.
Problems with the hemorrhoids are typically felt by itching, moisture in the anal area, bright red blood or mucus on the toilet paper. The defecation may feel incomplete and cause pain.As a rule, it is sufficient for the physician to look at (with the rectoscope) and to scan the vascular nodes bulging in the anal canal in order to make the diagnosis. While not necessarily pleasant, it does not last long and is also important to rule out other causes of the symptoms. The expert for this is the proctologist, who should take care of the medical treatment in more advanced cases.
Medical treatment: ointments, suppositories, outpatient procedures and surgeries
Our 10 most important tips against hemorrhoids
This has many different methods on offer. In the early stages, medical advice on chair control should be sufficient, provided that you actually implement the recommended measures. Often, ointments and suppositories with painkillers and anti-inflammatory agents (local anesthetics, cortisone, the plant medicine hamamelis, etc.) are prescribed. This is practical in the short term, but not a permanent solution. Especially since the skin can suffer from it. Above all, cortisone preparations are problematic with prolonged use, they increase the risk of fungal infection.
The medications can only help to temporarily relieve the symptoms. To reduce the size of the enlarged hemorrhoids with the help of a doctor, you have to put on a hand. This happens mostly on an outpatient basis. The different methods are basically all based on the same approach: local manipulation causes the vessels to become obstructed, thereby sclerosing and shrinking or dying. For this, special substances for injection (for example phenol almond oil), heating with infrared light, icing with nitrogen (only rarely) or a rubber band ligation for setting the vessels in question. The problem with all these procedures is the high rate of recidivism. This means that sooner or later the hemorrhoids will become noticeable again in many cases.
High recidivism rate for outpatient procedures
This is much less the case when operating classically to excise the perturbing hemorrhoids. But you have to go to hospital and usually several days there. Because the various, according to their respective inventors named surgical procedures are quite invasive, so the tissue neatly affected. Recent surgical procedures, such as Longo Stacker Hemorrhoidopexy, are seeking a gentler approach to reducing pain and shortening healing time. However, in the first few weeks after a hemorrhoid surgery, you will have to expect pain, especially if you have a bowel movement. However, given the good prospects for a - at least in this regard - uncomplicated life after that should be acceptable.
Problems eliminated, but not the causes ...
One thing you should be aware of in any case: With the medical treatment, even with surgery, not the causes are eliminated, which have led to the disturbing enlargement of the vascular pad. These relate above all to what is happening around the bowel movement. Definite harmful is frequent, too fast or too strong pressing, which leads to unfavorable pressure effects on the blood vessel coils. Chronic obstruction is often responsible for hemorrhoidal disease, with laxatives exacerbating the situation over time rather than improving it. Long sitting does not cause hemorrhoids problems directly, but it has a beneficial effect. On the one hand on the toilet, on the other hand in the office or on the sofa, where it goes hand in hand with a lack of movement. Of course, being overweight can not be denied as a disease-promoting cofactor.
(Actually) Simple prevention
Which brings us in the prevention - even before relapse after successful treatment! - have arrived: A high-fiber diet, a lot of exercise and a lot of drinking (especially water or unsweetened herbal teas) hemorrhoids do not even arise or disappear quickly. So a tip mantra that you can not recommend enough for other reasons.
Author: Dr. Hubertus Glaser